MÓDULO FORMATIVO 4

Reflective Paper and Commentary

The objective of this paper is to provide personal and professional reflections on the process of conducting this research. Due to the reflective nature it will be written using the first person. An extension of the methodological considerations and personal experiences that arose during the completion of Paper 2 will be provided. My personal experience of designing and conducting a research project within a National Health Service (NHS) Eating Disorder (ED) Service will be described. The final aim is to explore the themes and issues that arose throughout and the personal impact that they had.

Research Design Service User Involvement

The world of qualitative research was a new area of study and the idea of designing and constructing an interview schedule was somewhat overwhelming. Service user (SU) involvement and participation is a professional issue of particular interest and in line with best practice I was keen to ensure that I sought SU involvement from the early stages of the research project (Tait & Lester, 2005). I

met with a SU representative from within an NHS trust who had personal experience of binge eating difficulties, to discuss my ideas and research design. This meeting reinforced the message, which I had so often read about, that there is a huge lack of awareness of binge eating disorder (BED) both inside and outside of health services. This meeting left me feeling inspired and reaffirmed that I was completing a research project that would be meaningful.

Recruitment

I was fortunate to gain both university and NHS ethical approval near the beginning of my second year of training, which meant I had a reasonable period of time for recruitment and data collection. Recruitment started off well and I was able to recruit five participants within the first few months. However, following this initial period of data collection, recruitment appeared to hit a wall and there were no further potential participants identified. This created great feelings of anxiety due to the time pressures on the research project and being aware of the lengthy process of data collection, transcription and analysis. Further Research and Development approval was sought from an additional NHS Trust, and whilst this lessened my anxiety in the first instance it soon became apparent that it was unlikely to yield any further participants. I definitely underestimated the timeframe in which it would take to recruit sufficient numbers for the project; it look seven months to recruit eight participants in total. This period of uncertainty and the knowledge that I did not have control was challenging to tolerate and was managed through supervision and peer support.

The recruitment period allowed me to reflect on the challenges of conducting research within clinical practice and in particular, recruiting from a team that I was not a member of. In particular, recruiting from a service that was going through Management of Change meant that I needed to be mindful of these changes when prompting the team regarding recruitment. The balance of managing my own anxiety and motivation to recruit and not putting unnecessary

pressure on the team was difficult to manage at times. Reflecting on this with my clinical supervisor, it was decided that I should take a step back and allow them to continue to prompt the team. In addition to these management changes being in progress, members of the clinical team also shared with my clinical supervisor some ambivalence towards the research being conducted within the service. Whilst the project was well received when I presented at the multi- disciplinary team meeting, staff consequently shared that they had concerns about individuals feeling pressured to take part. This added increased anxiety for me during a time when recruitment had come to a standstill for a number of months, as I felt I was not being proactive and ‘doing something.’ With hindsight, I wonder whether staff might have felt cautious of being held under scrutiny by the research; for this reason it was important when meeting with the team that I emphasised that the research was focusing on the treatment seeking experience, not specifically discussing the treatment individuals are receiving. It might have been useful to meet with the clinical staff to allow them to share their concerns and to think about how this could be managed; however due to the external and internal pressures staff were being faced with it was decided that this would not be appropriate.

Personal Reflections Counter Transference

Due to five participants being interviewed within a short time frame this meant that transcription was completed in an intense block. Following advice from both supervisors and peers I was determined to keep on top of transcription, which meant that I completed these initial interview transcripts over three consecutive days. I was struck by how immersing myself into the data and ‘re-entering the participants’ world’ brought food, shape and weight to the forefront of my mind (Smith, Flowers, & Larkin, 2009). I was aware throughout transcription that the dialogue that was both being listened to and transcribed was focused on food, which left me feeling preoccupied with hunger. It was useful

to process and consider my personal responses with my clinical supervisor and to ensure I had adequate time ‘away’ from the data during both transcription and analysis. It has been documented that working within the field of EDs can commonly influence treatment providers’ attitudes and relationships with food and eating (Franko & Rolfe, 1996). More recently, treatment providers for EDs reported that their view of food changed over time and that they became more aware of aspects of their own and other people’s appearances (Warren, Crowley, Olivardia, & Schoen, 2009).

Conflicting Roles: The Therapist vs. The Researcher

Throughout the interviews, I often felt torn between my role as a researcher and a therapist. There were times that participants were describing thought patterns, which from a cognitive behavioural perspective could be considered as negative automatic thoughts. In my third year specialist placement I am predominantly working using a cognitive behavioural framework and the focus on these clinical skills and Socratic questioning may have made me particularly attentive to noticing these thought processes and patterns. It was difficult to maintain my role as a researcher and to refrain from challenging these negative thoughts within the interviews. This led me to reflect on whether as a Trainee Clinical Psychologist I was able to truly leave my ‘therapy hat’ at the door when conducting the research interviews.

I noticed conflict between my role as a researcher and as a therapist, in particular when I experienced a strong emotive response within an interview; this was the case for both positive and negative emotional reactions. A large proportion of the women who took part in the interviews expressed their gratitude at BED being given research attention. Hearing this positive feedback was encouraging and maintained my motivation, which was helpful to hold onto during periods of stress, particularly when managing the demands of my clinical placement, research write up and my personal life.

The emotional reactions I experienced at times mirrored the emotional content that participants expressed, which could be described as countertransference in Psychodynamic Theory (Malan, 1995). There were some participants who expressed a strong sense of worthlessness. In these situations, I can recall experiencing intense feelings of sadness and was drawn towards wanting to use my clinical skills in reflecting back to the participant and recognising their personal strength and resilience. This presented me with a dilemma in which I wanted to alleviate the participant’s distress; however I was aware of my role as a researcher and tried to resist engaging in therapeutic conversation. This is a common experience and demonstrated the tension that can arise between the roles of being a scientist and practitioner (Beutler, Williams, Wakefield, & Entwistle, 1995). Supervision was important during these times to think about my role and my own personal reactions to the interviews I was engaging in and also transcribing.

Throughout the entirety of the research I was able to build upon my skills as a researcher and to utilise the skills I was developing whilst being on placement. My clinical skills were fundamental to engaging participants and to ensure they felt comfortable and sufficiently supported to share with me their personal experiences, especially as it was a one off interview there was a relatively short time frame to build up rapport.

‘Eating Disorders Have No Gender’

Although there was no gender specified on the inclusion criteria for my research paper, it was notable that there were no male participants. Anecdotally it was apparent through conversations with my clinical supervisor that there were no males actively involved in the service that had a diagnosis of BED during recruitment (May 2015 – January 2016). At the time of writing this reflective paper, there is a current drive to increase awareness of male mental health, including EDs. Notably the Men Get Eating Disorders Too (MGEDT) Charity

have released a documentary called ‘Millstone’ (MGEDT, 2015), which shares the experiences of nine men who have experienced or are experiencing eating difficulties; the main message from this campaign reads as ‘eating disorders have no gender.’ In addition to the increased media attention of male EDs there has also been a focus on male mental health. In October 2015, the documentary ‘Suicide and Me’ featuring Professor Green explored male suicide in an attempt to challenge the stigma often associated with male mental health.

Weight, Shape and Society

Parallel to this positive movement in increasing the public awareness of male mental health, there is an abundance of ‘documentaries’ that focus on weight. The titles of some of these documentaries include ‘Benefits: too fat to work’; ‘My Big Benefits Family’; and ‘Shut Ins: Britain’s Fattest People.’ These documentaries are only a few of the programmes that have been aired on British Television in 2015. Society’s view of weight, particularly being overweight and/or obese and the shame and stigma associated with this was a powerful theme throughout almost all of the interviews. Having had the privilege of participants sharing with me their personal accounts of treatment seeking for binge eating and hearing that some of the barriers included societal and self-stigma, this left me feeling angry that such documentaries were being aired on television and the perpetuating role this could have on society’s view of obesity.

The literature pertaining to gender and weight has been critically examined and it has been highlighted that the very concept of being ‘fat’ has been feminised (Bordo, 2004). A recent analysis of newspaper representations of EDs in males suggested that men with EDs are represented as atypical of men and that feminine or de- masculinising characteristics are frequently associated (MacLean et al., 2015). I was aware of my role as a white female researcher in my mid-twenties and wondered what impact this might have on the responses participants gave within the interviews. I reflected on the

notion of my role possibly reinforcing the fact that EDs are often associated with female public health and that a large proportion of research is conducted using female participants.

The Value of Diagnosis?

The reliability and clinical utility of diagnostic tools and categories is a controversial topic within the field of psychology. Given the emphasis on social constructionism and the ‘critical approach’ of the Staffordshire and Keele Doctorate in Clinical Psychology programme, this has been a hot topic of debate throughout teaching. I was struck by the number of participants who shared with me the value of receiving their diagnosis of BED and the personal meaning this held for them. For a number of participants receiving a diagnosis of BED was a validating and critical part of their journey to seeking specialist treatment. This allowed me to reflect on the positive impact such diagnoses can have for individuals, for many this diagnosis meant that they were then eligible and met the necessary criteria in order to access specialist treatment. This highlighted the importance placed upon diagnostic criteria by services. The way in which NHS services are currently set up within mental health reinforces the use of specific diagnoses, as this is frequently a criteria for accessing specialist treatment.

Professionally, my thinking is in line with the recent Division of Clinical Psychology response to the DSM-5 (2013), which advocates formulation over diagnosis. Conducting this research has however allowed me to take into account the usefulness of receiving a diagnosis for some individuals and the importance of exploring this on an individual basis.

Discussion with SUs in the development of the research design and the interview schedule also raised the topic of the language used and it was decided that eating difficulties rather than eating disorder would be more appropriate. When listening back to transcripts I noticed that I said the words ‘binge eating’ in a quieter and more

tentative manner in comparison to the rest of the sentence. This could have been a result of wanting to get the wording ‘right’ and to try and be sensitive to the participant due to my own uncomfortable feelings with the diagnostic label. Transcribing after each interview allowed me to pick up on such nuances and processes, which were rife within each interview. Awareness of this permitted useful discussions within supervision and this allowed me to further reflect on the possible exacerbating impact this could have on the associated stigma with BED. I was therefore able to ensure that I did not collude with this stigma and say the words with confidence.

Summary

Throughout each and every one of the interviews conducted I felt in a privileged position to hear the individual stories and experiences from participants. I was struck by the candid nature of the women and their resilience throughout their journey to seek specialist treatment. I have developed both personally and professionally throughout this research project, specifically within my research skills, and this has reaffirmed to me the importance of supervision and self- reflection within a research role. I have had to tolerate uncertainty and manage being in a position of limited control, particularly during the early stages of the research.

References

Beutler, L. E., Williams, R. E., Wakefield, P. J., & Entwistle, S. R. (1995). Bridging scientist and practitioner perspectives in clinical psychology. American Psychologist, 50(12), 984. doi: 10.1037/0003-066X.50.12.984

Bordo, S. (2004). Unbearable weight: Feminism, western culture and the body. London: University of California Press Ltd.

Division of Clinical Psychology. (2013). Classification of behaviour and experience in relation to functional psychiatric diagnoses: Time for a paradigm shift DCP Position Statement. Leicester: British Psychological Society. Retrieved from http://www.bps.org.uk/system/files/Public%20files/cat-

1325.pdf

Franko, D. L., & Rolfe, S. (1996). Countertransference in the

treatment of patients with eating disorders. Psychiatry: Interpersonal & Biological Processes, 59(1), 108–116. doi: 0.1521/00332747.1996.11024753

MacLean, A., Sweeting, H., Walker, L., Patterson, C., Räisänen, U., & Hunt, K. (2015). “It’s not healthy and it’s decidedly not

masculine”: A media analysis of UK newspaper representations of eating disorders in males. British Medical Journal Open, 5, doi: 10.1136/bmjopen-2014-007468.

Malan, D. (1995). Individual Psychotherapy and the Science of Psychodynamics. London: Edward Arnold Ltd.

Men Get Eating Disorders Too. (2015). MGEDT documentary

Millstone. Retrieved from http://mengetedstoo.co.uk/mgedt- documentary-millstone-now-available-to-watch-online

Smith, J.A., Flowers, P., & Larkin, M. (2009). Interpretative

Phenomenological Analysis: theory, method and research. London: Sage Publications.

Tait, L., & Lester, H. (2005). Encouraging user involvement in mental health services. Advances in Psychiatric Treatment, 11, 168- 175. doi: 10.1192/apt.11.3.168

Warren, C. S., Crowley, M. E., Olivardia, R., & Schoen, A. (2009). Treating patients with eating disorders: An examination of treatment providers’ experiences. Eating Disorders, 17 (27), 27-45. doi: 10.1080/10640260802570098

Appendix A: Guidelines for Submission to the European Eating Disorders Review

Submission guidelines for authors

European Eating Disorders Review

Copyright © 2015 John Wiley & Sons, Ltd. and Eating Disorders Association Edited By: Professor Fernando Fernandez-Aranda

Impact Factor: 2.252

ISI Journal Citation Reports © Ranking: 2013: 34/111 (Psychology Clinical)O

Online ISSN: 1099-0968

Author GuidelinesL Manuscript Submission

European Eating Disorders Review has now adopted ScholarOne Manuscripts, for online manuscript submission and peer review. The new system brings with it a whole host of benefits including:

 Manuscript style. All submissions should be double-spaced and clearly legible.

 The first page should contain the title of the paper, full names of all authors, th address where the work was carried out, and the full postal address including telephone, fax number and email to whom correspondence and proofs should be sent.

 Abstract of up to 150 words. An abstract is a concise summary of the whole paper, not just the conclusions, and is understandable without reference to the rest of the paper. Include up to five keywords that describe your paper for indexing purposes.

 Review articles should offer a synthesis of current knowledge in a field where rapid or significant progress has been made. The text should ideally not exceed 7000 words, 50 references and 5 figures or tables.

 Reference style . The APA system of citing sources indicates the author's last name and the date, in parentheses, within the text of the paper.

Appendix B: DSM-5 Diagnostic Criteria for Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder

Diagnostic Criteria - Anorexia Nervosa

A. Persistent restriction of energy intake leading to significant low body

weight (in context of what is minimally expected for age, sex, developmental trajectory and physical health.

B. Either an intense fear of gaining weight or becoming fat, or persistent

behaviour that interferes with weight gain (even though significantly low weight)

C. Disturbance in the way one’s body weight or shape is experienced,

undue influence of body shape and weight on self-evaluation or persistent lack of recognition of the seriousness of current low body weight.

Subtypes:

Restricting type

Binge-eating/purging type

Diagnostic Criteria - Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is

characterised by both of the following:

 Eating, in a discrete period of times (e.g. within any 2-hour period), an

amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

 A sense of lack of control over eating during the episode (e.g. a feeling

that one cannot stop eating or control what or how much one is eating).

B. Recurrent inappropriate compensatory behaviour in order to prevent

weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting or excessive exercise.

C. The binge eating and inappropriate compensatory behaviours both

occur, on average, at least once a week for three months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of

Diagnostic Criteria – Binge Eating Disorder

A. Recurrent episodes of binge eating. An episode of binge eating is

characterised by both of the following:

 Eating, in a discrete period of time (e.g., within any 2-hour period)

an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.

 A sense of lack of control over eating during the episode (e.g., a

feeling that one cannot stop eating or control how much one is eating).

B. The binge-eating episodes are associated with three (or more):

 Eating much more rapidly than normal.

 Eating until feeling uncomfortably full.

 Eating large amounts of food when not physically hungry

 Eating alone because of feeling embarrassed by how much one

is eating.

 Feeling disgusting with oneself, depressed, or very guilty